As you know, medical costs to treat injuries and sicknesses caused in the course of work or commuting are not covered by Employee’s Health Insurance. Such work-related injuries and illnesses are normally covered by Workers’ Accident Compensation Insurance. The major advantage of Workers’ Accident Compensation Insurance is that it provides full coverage for such medical costs while Employee’s Health Insurance coverage remain 70%. Among several benefits provided by Workers’ Accident Compensation Insurance, a payment to reimburse medical costs is called Medical Compensation Benefit. This is the most common benefits claimed with Workers’ Accident Compensation Insurance. This column will explain how to make a claim for this benefit.

Who is eligible?

To be eligible to receive Medical Compensation Benefit from Workers’ Accident Compensation Insurance, you must be granted as a “worker”. Claims should be made by the following people or an entity.

Insured worker himself or herself

Family member of insured worker

Employer

Have treatments at designated medical institution

If you have a work-related injury or illness, it is recommended to have medical treatments at a designated medical institution of Workers Accident Compensation Insurance, if possible. This is because your medical costs can be fully covered and there will be no payment at such a designated clinic if you hand in the required documents on the day. Of course your medical expenses will eventually be reimbursed even though you had treatments at non-designated institution. However, you will have to pay the cost in full first, then make a claim for a reimbursement. Note that required documents and procedures to claim vary depending on the type of medical institution at which you were treated and whether the accident occurred during the course of your job or commuting.

※No matter the type of medical institution you are in, make sure to advise your care provider that your injury or illness is caused by work-related accident.

Required documents

To claim benefits with Workers’ Accident Compensation Insurance, you need to provide the following documents. The claim form can be obtained from a branch office of Labour Standards Inspection Office as well as from the website of Ministry of Health, Labour and Welfare.

Designated medical institution

Medical Treatment Benefits Claims Form: Form No.5 for an accident during working, Form No.16-3 for an accident during commuting

※A claim form should be passed to the medical institution at which you have treatments.

Non-designated medical institution

Medical Treatment Benefits Claims Form: Form No.7 for an accident during working, Form No.16-5 for an accident during commuting

Supporting documents such as a payment receipt or tax invoice issued by the medical institution and doctor’s certificate (to be attached with a claim form)

※Those documents should be submitted at the nearest Labour Standards Inspection Office.

Procedures to make a claim

Designated medical institution

Notify your employer of that you have a work-related injury or illness

Fill in the Medical Treatment Benefits Claims Form and ask your employer to certify the content

Advise your doctor it is work-related injury or sickness, hand in the documents and have treatments

The medical institution will complete the rest of procedures and you have no further action to do

Non-designated medical institution

Notify your employer of that you have a work-related injury or illness

Fill in the Medical Treatment Benefits Claims Form and ask your employer to certify the content

Advise your doctor it is work-related injury or sickness and pay the medical expenses in full

Get a payment receipt

Attach the receipt to the claim form and submit all the documents at the nearest Labour Standards Inspection Office

The medical expenses you have paid will be reimbursed once your application is approved by Labour Standards Inspection Office

Reminder

As a general rule, Employee’s Health Insurance cannot be used to cover medical costs for treatments of work-related injury or illness. Make sure to let your doctor know that you have a work-related injury or sickness

If you couldn’t prepare required documents at the time of first visit, ask your doctor or hospital staff what you should do. Some hospitals let you have medical treatments for free without a claim form if you can hand it in at a later date. In such a case, make sure to ask them the deadline to give them a claim form.

You receive a payment from Workers’ Accident Compensation Insurance only if Labour Standards Inspection Office approves that your case is a work-related accident.

Even if your employer refused to certify your claim, you may file your claim with Employee’s Health Insurance without their declaration. In such a case, an assessment may take longer than usual. Therefore, you should ask your employer for to certify your document at least once.

There is a deadline to make a claim with Employee’s Health Insurance. To receive Medical Compensation Benefit, you must file your claim within 2 years starting on the next day you made a payment for medical expenses, or the next day the amount of your medical costs were confirmed.

Is your injury work-related?

Many people misunderstand that they can use Employee’s Health Insurance for medical treatments of work-related injuries or sickness, and they actually to do so without knowing it is banned. But now you know you should use Workers’ Accident Compensation Insurance if you get injured or sick while working. In fact, making a claim with Workers’ Accident Compensation Insurance is easy. If you have a medical treatment at a designated hospital, you don’t even pay for it just by submitting a claim form. Even when you had a treatment at a non-designated clinic, you can receive a reimbursement by sending a payment receipt, doctor’s certificate and claim form.

Writer

Kotoho Akira

Living outside Japan for a good many years, I often rediscover nice little things about this country every time I return here. I would be more than happy if this column may help you find your "nice little things about Japan"!